ch. 23 physiologic behavior and adaptation of the newborn at birth

Question 1

neonatal period: newborn physiologic adjustment tasks involve

Answer 1

birth to 28 days

1) newborn physiologic adjustment tasks involve
- establishing and maintaining respirations
- adjusting to circulatory changes
(a) closure of patent ductus arteriosis
(b) closure of foramen ovale
(c) closure of ductus venosis
(d) decrease in pulmonary resistance, increase vascular resistance
- regulating temperature
- ingesting, retaining, and digesting nutrients (human milk/formula)
- eliminating waste
- regulating weight (lose up to 10% body weight) -> will return in 2 weeks

Question 2

neonatal period: newborn behavior tasks include

Answer 2

• establishing a regulated behavioral tempo independent of the mother, which involves self regulating arousal, self monitoring changes in state, and patterning sleep
• processing, storing, and organizing multiple stimuli
• establishing a relationship with caregivers and the environment

Question 3

stages of transition to extrauterine life

Answer 3

1) major adaptations associated with transition from intrauterine to extrauterine life occur during the first 6-8 hours after birth

2) first period of reactivity:
- lasts up to 30 minutes after birth
- newborn’s heart rate increases to 160-180 bpm but gradually decreases after 30 minutes

3) periods of decrease responsiveness
- lasts from 60-100 minutes
- after first period reactivity, newborn either sleeps or has a marked decrease in motor activity
- pain, sleep/wake stress

Question 4

stages of transition to extrauterine life

Answer 4

• occurs 2-8 hours after birth
• lasts from 10 minutes to several hours
• tachycardia, tachypnea occur
• increased muscle tone
• improved skin color
• mucous production
• meconium typically passed

Question 5

physiologic adaptation: respiratory

Answer 5

1) initiation of breathing
- chemical factors: activation of chemoreceptors in carotid arteries/aorta
- mechanical factors: changes in intrathoracic pressure (decreased pulmonary pressure as newborn takes in air)
- thermal factors: stimulation of skin + respiratory center in the medulla (site for respiration in brain)
- sensory factors: suctioning, drying, lights, sounds, smell

2) establishing respiration

3) signs of respiratory distress:
- nasal flaring
- intercostal or subcostal (subclavicular, substernal) retractions
- grunting (no strong cry, trying to cry out but can’t, piggy sounds)

4) acrocyanosis:
- normal finding in the first 24 hours after birth
- blue hands/feet

Question 6

fetal respiratory system

Answer 6

1) fetal lung development
(a) 20-24 weeks
- alveolar ducts appear
(b) 24-28 weeks
- primitive alveoli
- alveoli epithelial cells differentiate into type 1 (structures necessary for gas exchange) and type II (structures that provide for synthesis & storage of surfactant) -> 8 months
- between 24-28 weeks, the # of type II cells increases

2) surfactant:
- surface active phospholipids critical for alveolar expansion, stability
- production peaks at 35 weeks (adequate)

3) intermittent detal breathing movements develop chest wall muscles
- diaphragm
- betamethasone, dexmethasone, ambubag, suction, CPAP/vent, fetus breathes in utero

Question 7

ability to maintain respiratory function

Answer 7

1) lung compliance
(a) influenced by:
- elastic recoil of lung tissue
- anatomic differences in newborn
- large heart and abdomen
- high diaphragm

2) airway resistance
- depends on radius length and number of airways

Question 8

cardiopulmonary adaptation

Answer 8

1) neonate’s first breaths initiate sequence of events
- airways emptied of fluid
- volume, function established
- fetal circulation converts to neonatal

Question 9

characteristics of newborn respiration

Answer 9

• normal rr: 30-60 breaths/min
• periodic breathing
• nose breathers
• cyanosis (complete blue)
• acrocyanosis (blue hands/feet)
• use of intercostal muscles (retractions, may indicate distress)

Question 10

cardiopulmonary adaptation: major changes (EXAM)

Answer 10

1) increased systemic vascular resistance/decreased pulmonary vascular resistance -> need ability for blood to get through lungs -> expand -> contract

2) closure of foramen ovale

3) closure of the ductus arteriosus

4) closure of the ductus venosus

Question 11

fetal circulation

Answer 11

1) placenta: organ of gas exchange (lifeline for fetus)

2) blood bypasses the lungs in utero

3) blood directed from R atrium across foramen ovale (FO) into the L atrium

4) 60% of ventricular output bypasses lungs to flow through ductus arteriosus (DA) into the descending aorta (shunts blood from R ventricle -> decending aorta (mixes blood))

5) mixing of oxygenated blood results in a sat rate of 45% that can perfuse lower part of the body

6) vascular resistance low (30-50%)

Question 12

cardiopulmonary changes

Answer 12

1) ductus arteriosus:
- R vent -> pulmonary circulation

2) foramen ovale:
- R atrium -> R ventricle

3) ductus venosus:
- blood flow to liver

4) cord blood gases
- 2 arteries, 1 vein

Question 13

characteristics of newborn cardiac function

Answer 13

1) heart rate:
- 110-160 in first week of life
- apical rates should be obtained by auscultation for one full minute after initial stabilization
- HR may drop as low as 70 during sleep (transient)
- PDA NOT completely closed

2) blood pressure (BP):
- highest immediately at birth, lowers at 3 hours of age
- vary with birth weight, age
- cap refill less than 3 seconds (sterum)
- avg. mean BP: 31 - 61 mmHg

3) heart murmurs:
- transient in 90% of cases -> murmurs heard in first 48 hours need follow up (grade 2)

Question 14

hematopoietic adaptation: oxygen transport

Answer 14

1) mean hgb: 17 g/dL

2) 70-90% of hgb is hgb F
- greater affinity for oxygen than HgB A

3) alkalosis (higher pH) and hypothermia can result when less O2 is available body tissues

4) hgb F declines first 2 months of life (enough hgb A available for O2 transport)
- physiologic anemia of the newborn (trauma, bleeding accident, MVA)

5) by 3-5 days of life, nucleated RBC’s are no longer found in blood of term or preterm infants

Question 15

hematopoietic adaptation: coagulation

Answer 15

1) absence of intestinal flora to synthesize vitamin K in newborn (can’t adequately synthesize vitamin k -> risk bleed)

2) transient neonatal thrombocytopenia

3) mothers with severe HTN, HELLP syndrome, or idiopathic isoimmune thrombocytopenia
- eg. male circumcision

Question 16

delayed cord clamping

Answer 16

1) placental transfusion
- blood from placenta passes to newborn

2) ideal timing not established
- many hospitals now wait one minute before clamping cord
- may wait for placental separation

3) may facilitate transition from fetal to neonatal circulation
- easier -> more pump to mom

4) positive effects in clinical trials for preterm infants
- fewer blood transfusion for babies

Question 17

physiologic adaptations

Answer 17

1) thermogenic system: goal of care is to help newborn achieve thermal balance in adjusting to extrauterine environmental temperature
- thermoregulation: the maintenance of balance between heat loss and heat production
- hypothermia
- heat loss
- thermogenesis
- cold stress
- hyperthermia (37.5+)

Question 18

types of heat loss

Answer 18

1) convection: heat from the body to cooler air
- AC, fan

2) radiation: heat from body to cooler indirect surfaces
- cold facet near
- INDIRECT

3) evaporation: loss of heat as liquid is converted to vapor
- moisture
- keep baby dry

4) conduction: loss of heat to direct cooler surfaces
- cold warmer skin to skin
- DIRECT

Question 19

cold stress

Answer 19

breakdown of systems

Question 20

thermogenesis: heat production in the newborn

Answer 20

1) non shivering thermogenesis (NST):
- uses brown adipose tissue (BAT, brown fat) to provide heat
- stores of fat that promote rapid metabolism, heat generation, and heat transfer (cover major organs)
- activates of newborn is cold

2) shivering rarely seen in newborn
- lips turn blue
- pale

3) increased basal metabolism
- effects of cold, drugs

4) ability to produce heat altered by hypoxia, acidosis, hypoglycemia
- low body temp
- GDM mom -> at risk hypothermia

5) also medications that block release of norepinephrine (analgesic, anesthetic)
- affect heat
- affect ability to counteract cold

6) newborn hypothermia prolongs & can potentiate effects of analgesic & anesthetic drugs in newborn

Question 21

hepatic adaptations

Answer 21

1) essential functions:
- production of bile
- regulation of plasma proteins, glucose
- biotransformation of drugs, toxins

2) neonate less than 20% of hepatocytes that are present in adult liver

3) liver growth continues until maturity

Question 22

physiologic adaptations: hepatic system

Answer 22

1) iron storage
- fetal liver begins storing iron in utero

2) glucose homeostasis

3) fatty acid metabolism

4) bilirubin synthesis: unconjugated to conjugated

5) jaundice
- unconjugated bilirubin can’t be excreted into urine -> goes into blood/brain barrier
(a) physiologic jaundice: appears after 24 hours, peak 3 days, feeding related, very common in preterm babies, <13mg/dL, resolves with breastfeeding
(b) pathologic jaundice: 1st 24 hours, cause: ABO incompatibility, treatment: phototherapy (NICU), exchange transfusions

Question 23

physiologic jaundice

Answer 23

1) accelerated destruction of fetal RBCs
- normal

2) occurs after the first 24 hours of life

3) 60% term, 80% preterm

4) daylight assists in early recognition

5) during 1st week, bilirubin should NOT exceed 13 mg/dL (touch sternum x3 postpartum)

6) peaks 3-5 days in term newborns then declines

7) more prevalent in breastfed babies

8) nursing care for jaundice (monitor, encourage feedings)
- phototherapy: UV light, vitamin D -> resolves jaundice
- breaks down bilirubin

Question 24

physiologic adaptation: hepatic system r/t breastfeeding

Answer 24

2 forms of breastfeeding-related jaundice

1) breastfeeding does NOT cause the jaundice, rather lack of effective breastfeeding that contribute to the hyperbilirubinemia

(a) breastfeeding associated jaundice
- EARLY onset jaundice

(b) breast milk jaundice
- LATE onset jaundice

Question 25

conjugation of bilirubin

Answer 25

1) breakdown of heme-containing proteins

2) conjugation:
- conversion of fat to water soluble
- total serum bilirubin (transcutaneous bili)
- conjugated and unconjugated

3) after birth, liver must conjugate bilirubin
- establish gut motility, active stooling
- early feedinh

4) total bilirubin = sum of conjugated (direct) + unconjugated (indirect) bilirubin

Question 25

glucose homeostasis

Answer 25

1) glucose not used for energy is converted to glycogen & stored in liver, heart, and muscles

2) fetal glucose levels 80% of mother’s glucose level (worry if GDM, mom high BS -> fetus high BS)

3) glucose main source of energy 4-6H after birth

4) fuel source consumed quickly

5) assess glucose level of newborn (can go hypoglycemic d/t losing source of glucose from mom)
- nadir at about 1-2 hours of age post clamping

Question 26

gastrointestinal adaptations

Answer 26

1) digestion and absorption
- adequate intestinal and pancreatic enzymes
- proteins require more digestion
- absorbs and digests fats less efficiently
- experienced swallowing, gastric emptying in utero (swallow/urinate/stool in utero)
- air enters stomach immediately after birth (first breath)
- 50-60 mL capacity (30cc/oz) (60cc/2oz)
- cardiac sphincter immature
- monitor regurgitation (stomach doesnt have capacity (newborn marble, infant golfball)
- REQUIRES 120 kcal/kg/day
- 5-10% shift of intracellular fluid

Question 27

gastrointestinal adaptations: elimination

Answer 27

1) term newborns pass meconium within 24 hours of life & almost always within 48 hours

2) meconium: formed from amniotic fluid, intestinal secretions, & mucosal cells (black, tarry stool)

3) transitional stools (brown/green)

4) breastfed (yellow, seedy, watery)

5) formula

6) frequency varies

Question 28

physiological adaptations: renal system

Answer 28

1) an infant who has not voided by 24 hours should be assessed for:
- adequacy of fluid intake
- bladder distention
- restlessness
- signs of discomfort

2) flid and electrolyte balance

3) signs of renal system problems
- doesn’t void 24H newborn

Question 29

key facts: physiologic adaptations to extrauterine life

Answer 29

1) periodic breathing may be present
- RR: 30-60
- HR: 110-160

2) desired skin Temp:
- (36-36.5 initial) -> (26.5-37.5)
- stabilizes 4-6 hours after birth

3) desired glucose level reaches 60-79 by 3rd day
- initial: 40-45+

4) progression of stool:
- meconium
- transitional (thin, brown to green)
- formula fed (pale, yellow, formed/pasty)
- void/stool first 24 hours, if not -> 48 hours

Question 30

physiologic adaptations: integumentary system

Answer 30

• vernix caseosa: cheesy coating in crevices, moisturizer for baby, let absorb in skin
• sweat glands; milia: sebaceous glands, white dots nose
• desquamation: blotching of skin
• mongolian spots: big bruise on lower back, buttocks, thighs
• nevi: nevus flammeus (port wine stains), slate gray nevi
• infantile hemangioma: strawberry marks, elevation of blood vessels (forehead/chest) -> will disappear in time)
• erythema toxicum: newborn rash, white circle with redness (hormone transfer from mother)
• signs of integumentary problems

Question 31

immunologic adaptations

Answer 31

1) neonatal defense against infection in utero & after birth is dependent on maternal immunity (what disease does mom have)

2) neonates lack immunologic memory

3) slower capacity to develop immune responses

4) newborn at risk for bacterial, viral infections that result in increased mortality (good hand hygiene)

5) functions of immune system:
(a) defense: fights microorganism
(b) homeostasis: disposition of worn out cells
(c) surveillance: recognition & destruction of foreign or aberrant cells

6) nonspecific & specific immune components
- phagocytosis
- inflammatory response
- complement
- coagulation

Question 32

nonspecific immune responses

Answer 32

1) phagocytosis:
- major mechanism to remove pathogens & cell debris

2) inflammatory response:
- complex biologic response of vascular tissues to harmful stimuli such as pathogens, damaged, cells, or irritants

3) complement:
- helps the ability of antibodies & phagocytic cells to clear pathogens from an organism (boost pathogens)

4) coagulation:
- process by which blood forms in a clot (seal area so bacteria can’t get in)

these functions identified early in pregnancy; reach functional development at 32-33 weeks (evolve after baby is born)

Question 33

specific immune response: humoral immunity

Answer 33

1) consists of cell mediated (t cell) & humoral (b cell) systems

2) specific antibody-mediated response that functions most effectively in a recent exposure to infection

3) develops 7-12 weeks gestation

4) newborns have decreased ability to have effective antibody responses

5) active acquired immunity: pregnant women forms antibodies in response to illness, immunization

6) passive acquired immunity: antibodies transferred to fetus in utero

Question 34

specific immune response: cellular immunity

Answer 34

1) mediated by t lymphocytes to enhance efficiency of the phagocytic response

2) activated by antigens to which they have become sensitized

3) types of activated t cells:
- cytotoxic: kills foreign on virus infected cell
- helper: enables t or b cells to respond to antigens
- suppressor: represses responses to b or t lymphocytes to antigens

4) t lymphocytes modifying behavior of phagocytic cells to increase antimicrobial activity
- HIV -> low T cells which affect whole body

Question 35

physiologic adaptations: neuromuscular system

Answer 35

1) almost completely developed at birth
2) normal tremors, tremors (jitteriness) of hypoglycemia, and seizure activity must be differentiated
3) newborn reflexes:
- sucking
- rooting
- moro
- palmar grasp
- babinski toes -> adult CNS injury

Question 36

characteristic of newborn neurologic function

Answer 36

1) affected by perinatal factors: complications during pregnancy

2) intensity of motor activity influenced by:
- sleep wake states
- presence of environmental stimuli
- conditions causing chemical imbalances
- hydration status (fed? hydrated?)
- state of health
- recovery from stress of labor, birth

Question 37

behavioral adaptations: newborns progress through a hierarchy of behavioral developmental challenges

Answer 37

1) regulate their physiologic or autonomic system

2) regulate or control their motor behavior

3) state regulation, the ability to modulate the state of consciousness

4) attention and social interaction

Question 38

behavioral adaptations: sleep wake states

Answer 38

1) six states form a continuum from deep sleep to extreme irritability

2) the ability to make transitions between states is called state modulationb

Question 39

behavioral states of the newborn: sleep states

Answer 39

1) deep or quiet sleep
- 35-45% of total sleep

2) active/light sleep
- 45-50% of total sleep
- rapid eye movement (REM)

learn early to get accustomed to sound

Question 40

behavioral states of the newborn: alert states

Answer 40

1) 30-60 minutes after birth, newborns display quiet alert state

2) subcategories:
- drowsy or semi-dozing
- quiet alert
- active alert
- crying

Question 41

periods of reactivity

Answer 41

1) first period of reactivity:
- birth to about 30 minutes after birth
- bonding, initiate breastfeeding -> comfort, slows fast RR/HR
- respirations and heart rate rapid

2) inactivity to sleep phase:
- heart rate, respirations decrease
- sleep phase from minutes to 2-4 hours

3) second period of reactivity:
- awake and alert
- 4-6hours (first feed)
- physiologic responses vary (feed held)
- close observations
- GI tract more active

Question 42

intrauterine environmental influence on newborn behavior

Answer 42

1) intrinsic factors:
- maternal nutrition: prenatal care
- drug exposure: before/during labor

2) external environment: comforted, loved/held

3) individual temperament of newborn
- varying responses to stressors

4) exposure to auditory stimuli in utero
- manifested in behavior of newborn

Question 43

sensory/perceptual capacities of the newborn

Answer 43

1) visual capacity:
- orientation: ability to be alert to, follow, and fixate on complex visual stimuli
- prefers human face, high contrast

2) auditory capacity:
- definite organized behavior repertoire
- match assessment stimulus to state of newborn
- newborn hearing test

3) olfactory capacity:
- can differentiate mother by smell

4) taste and sucking:
- sweet & sour
- sucking patterns, rooting reflex

5) tactile capacity:
- may be most important
- very sensitive

Question 44

the nurse is assessing a newborn at 5 hours of age and finds a soft mass over the infant’s occiput. The soft mass crosses the suture line. The nurse documents this finding as which of the following?

Answer 44

caput succedaneum